An exploration of nurses’ use of history taking and physical assessment skills in adult acute care

Abstract

Amid growing concern for patient safety, the deterioration and mortality of acutely ill patients continue to be problematic and are a high priority of NHS England. Evidence has shown acute care patients are at risk of clinical deterioration when assessment is not comprehensive. Nurses are deemed best placed to identify changes in patients’ conditions to detect signs of clinical deterioration because they maintain a constant presence during the shift and get to know their patients. History-taking and physical assessment (HTPA) skills provide nurses with appropriate education and training, giving them the necessary skills to undertake a comprehensive assessment of patients. Yet, to date, few studies have adopted a qualitative approach to explore acute care nurses’ use of the skills in the context of the clinical setting. A hermeneutical-dialectical methodology was adopted to explore the perceptions of participants of factors that influenced nurses’ use of HTPA, changes to nursing practice, and the impacts on patient care. The study took place in acute care services across four hospitals. A two-staged qualitative approach consisted of five focus groups of 18 nurses and four focus groups of 15 managers, followed by 13 nurse semi-structured interviews. Braun and Clarke’s thematic analysis revealed that participants perceive nurses’ use of HTPA enhanced holistic care, continuity of care, and rapid intervention could improve patient outcomes. However, nurses’ ability to exercise these skills was limited by their role. Fundamentally, the ward nurse’s role lacked legitimacy and autonomy which constrained nurses from being able to use HTPA to assess acutely ill patients. Additionally, the lack of appropriate mentor support restricted ward nurses from developing their confidence and competence to use the skills in clinical practice. Organisational workforce pressures associated with ‘firefighting and gap-filling’ due to the combination of excessive workloads and insufficient staffing numbers further impeded acute care nurses from using HTPA. Highlighting the challenges that acute care nurses currently face in using HTPA skills is pivotal for organisations and the nursing regulator to promote systems to be put in place to support nurses in their development and use of HTPA in clinical practice. Awareness of nurses’ challenges in using HTPA is also aimed at those who provide the education and those that support nurses in clinical practice.

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